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Back to the future with Covid-19 as war talk dominates the discourse

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Professor Tim Quinlan is a senior research associate, and former Research Director, at the University of KwaZulu-Natal’s Health, Economics and HIV/AIDS Research Division (HEARD). He writes in his personal capacity.

Have we forgotten all the lessons we learnt from the HIV-AIDS pandemic? Of how to mobilise a multi-sectoral response and sensitive interventions? Instead, we are confronted by a ‘command centre’ that responds with metaphors of war. This is so wrong, on so many levels.

If I remember correctly, in the 1990s/early 2000s when war metaphors dominated explanations of the HIV-AIDS pandemic, a common question was: who are we fighting – the virus or the hosts? Déjà vu, with President Cyril Ramaphosa’s recent reference to South Africans being at “war” and in a “war zone” in relation to the current restrictions on people’s rights. The statement is ominous. In a war zone, the inhabitants are collateral damage, if not the enemy.

We are, of course, not at war. We are back on familiar ground in the face of the president’s and other ministers’ facile explanations of why the government is acting the way it is. The explanations are much like those of the government in the early 2000s when civil society was trying to get Thabo Mbeki and his ministers to understand science and provide antiretroviral treatment for HIV-infected people. This time, South Africans have the advantage of lessons learned from guiding the government towards constructive ways of curbing the HIV epidemic and from challenging the Zuma presidency.

There are factual explanations for the dire threat of the Covid-19 virus to the health and welfare of all who live in South Africa. For instance, the health system, as a whole and as it is, will never cope with this epidemic. This is evident from audits for the National Health Insurance scheme, research studies, the Health Ministry’s considerations about the human resource challenges, and continual revelations of management failings at many public and some private hospitals.

Furthermore, the government is undermining the efforts of doctors, nurses, ancillary staff, health NGOs, and volunteers. Illustrations include the belated consideration of regulations to prevent tenderpreneurs plundering Covid-19 designated funds, the apparent absence of coherent strategies, and the imposition of contradictory lockdown regulations.

All the while, there is the anguish within the increasing number of families who have lost loved ones. The majority of the country’s inhabitants are desperate. They are cold, hungry, unable to earn incomes and, probably for many, Covid-19 is the least of their concerns. Plus, there are those who have lost jobs and who, at best, are making ends meet for as long as their savings last and families and friends can help. 

To cap the situation, the government is grappling with uncertainty. The world does not know much about the virus beyond its immediate effects on people’s health, nor about how to revive local and national economies in this context.

My point, one that many others have made: society at large needs to think and act constructively in the face of this despair and uncertainty.  

A good starting point would be for the national executive to dump the “command and control” agenda. South Africa has better options, learned from dealing with the HIV epidemic.

Government assistance, co-ordination, and allocation of resources is essential. So too is the voluntary cooperation of many individuals and organisations and, ultimately, community-oriented planning and action – be that a company, church congregation, neighbourhood, squatter camp or town.

First, now that Covid-19 is endemic, the country will need to move, sooner rather than later, from a crisis response to managing the epidemic. 

There is nothing wrong in principle with “command and control” as an initial response to the Covid-19 virus. It is a tested standard for dealing with a major incident. Think firefighting. There is a fire captain and, irrespective of the number of individuals and crews involved, all act as the captain commands. They do so because all information is relayed through the captain who is thus in a position to co-ordinate the deployment of personnel and equipment for best effect.

Managing the epidemic is different. It is about what to do following an initial incident and for an extended period of time. HIV policy and strategy documents commonly refer to the need for “a multisectoral response” because the problem is too big for one agency to deal with on its own. They refer also to “national surveillance and monitoring” because the continual gathering and analysis of information is crucial for understanding where and how an epidemic is evolving; hence, for informing planning and action.

These documents refer to “context-sensitive” interventions. They do so because the effects of an epidemic are different in different populations and settings as is the availability of resources; hence, interventions need to be designed accordingly.

Government assistance, co-ordination, and allocation of resources is essential. So too is the voluntary cooperation of many individuals and organisations and, ultimately, community-oriented planning and action – be that a company, church congregation, neighbourhood, squatter camp or town. What this means strategically is that there has to be public access to, and sharing of information, civil society participation in planning and, particularly in Africa, NGO-led actions (in collaboration with local authorities and community organisations).

These are foundations for informed revision of interventions as circumstances change; indeed, for cultivating trust, solidarity and compassion.        

Second, there has to be a nuanced understanding of the risks of infection. In the early days of national HIV programmes, there was a focus on “most-at-risk populations”. The meaning has evolved with experience. For example, from acknowledging that women are most at risk, to recognising the particular risks and vulnerabilities of sub-populations such as adolescents, LGBTQI and disabled persons, to investigations on the clustering of HIV infection in particular settings. Devising sound interventions for those with particular risks and vulnerabilities requires their assistance; to identify the threats to their health and welfare and what interventions will and will not work. To borrow a common slogan from activists in these populations, the imperative is “nothing about us without us”. A good principle for medium to long-term, community-oriented Covid-19 interventions.        

Third, South Africa has accumulated expertise on community-oriented HIV treatment and support programmes. This is valuable. It can be used for local-level surveillance and monitoring and, also, for containing and then preventing the spread of Covid-19 infection in towns and other settlements. It can be used to alleviate the burden on bereaved families and those with members who struggle to recover their health and livelihoods. 

This comes from many years’ experience. Throughout Africa, religious and secular NGOs first assisted with home-based palliative care for people infected with HIV. Since the early 1990s, they have recruited settlement residents to become volunteer care workers or to provide whatever help they could (eg, farmers giving food for indigent families). Since the mid-2000s, they have helped clinic health teams reach into communities to provide antiretroviral treatment alongside supporting individuals, socially and economically. Many extended their expertise to include other activities such as care for the elderly. There are numerous individuals, NGOs and health professionals in South Africa who know how to do this work.

South Africa has the experience, expertise and will among its inhabitants to curb the epidemic. How does one revive local and national economies in these circumstances? I do not know. A suggestion: there are individuals and organisations in South Africa who have the professional skills and creative talent and who can show how to begin building a new economy.  

There is no place for war metaphors in this scenario. DM

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